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ILE COPY <br /> WELL•ERMIT APPLICATION AM S SITE <br /> SAN JOAQUIN COUNTY UUMITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EFWj'IR'0iblEN PLEW1h <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 """!T <br /> (209) 468-3449 03 AUG 19 PM 4: 19 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work descnbed. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin C6unty Environmental Health Department <br /> � �y� � Assessor' <br /> WELL Location 1. (� ����OL Cross Street 11 LV VY. City�T�p� QSPar= 1k7-6aD-0"J <br /> PROPERTY Owner_� f i [�I(V3t Vl041E.f Address �F/ City� _Z�p�Sal�Phone# 'Fj�`�( 7a <br /> C-57Contractor I t`e_tt Address jLe 0(YL CC city .h vrtYlplZL"Luc#1 non )b3$, II(99 <br /> Consultant I Sub Cntr It(re Address 7?,7 Shay-J Clty�ec.t4-I� Lic#kB02a-7 Phone# (adj)Nb 7—/0)6 <br /> GIS Coordinates:X Y Township L Range Section <br /> WORK TO BE PERF ED: <br /> ()NEW WELL/ ORING CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) (] DESTRUCTION (choose type below) <br /> SOIL BORING# rd- «tea ^+t ���.�i�� p OVER-SORE <br /> PRESSURE GROUT <br /> `Other. � lrxrC�raS 4_SQ� C 3 fxN m nl2 (9W Grout Specifications:�('�la.-v�1 C-2Yv�C- <br /> COMMENTS— -c-+ti <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> p MONITORING HOLLOW STEM DIA OF BOREHOLE j.;!-S- MULTIPLE CASINGS?0 MULTI-LEVEL?Q WELL CASING DIA <br /> EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS''�., TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 3 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL U4' kn TREMIE TYPE TO BE USED: )(AUGERS p HOSE <br /> ']AIR SPARGE/Ozone 0 PUSH POINT GROUT SEAL PUMPED: p Yes p No (NOTE: MAXIMUM FREE-PALL DEPTH IS 30') <br /> (SOIL BORING H HAND AUGER GROUT SPECIFICATIONS: <br /> OTHER: fl OTHER APPROX.BORING DEPTH 4 SA&jfjW HBOLTE TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, <br /> and all applicable California State Laws. <br /> Signed x "^�� �' ' Title/Company 5�aR QY' i <br /> Print Name D-I�nos_ �e. `�r Date - Q' s <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDR SS: //V A• <br /> WORK PLAN DATED: g^03 <br /> Application Accepted Issued Area <br /> epted By _ <br /> Grout Inspection By Date Final Inspection B _ to <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> o <br /> C-57W0/, ---WAIVER--- C-57 Letter of Authorization to sign permit_Encroachment doc_ 8/29/02 <br />